A recent analysis of the Affordable Care Act published on
the blog of Health Affairs showed the
Affordable Care Act will leave at least 29.8 million to as many as 31 million
persons uninsured by 2016 – depending on how many states eventually decide to
join the ACA’s Medicaid expansion provisions that expand coverage to
lower-income individuals.

Notably, 80 percent of the still-uninsured are projected to
be American citizens – amounting to some 24 million individuals. Most will be
white, working-age adults, many of them employed. Included in the projection
are 4.3 million children and one million veterans.

“The ACA will leave tens of millions uncovered,” the authors
summarized in their June 6 posting. “It will do little to alter racial
disparities in coverage. It will also perpetuate disparities in access based on
state of residence. The ACA, whatever its merits, will fall well short of its
stated goal of providing affordable care for all Americans.”

The analysis was done by Dr. Rachel Nardin and four
colleagues from Harvard Medical School.

Two leading researchers say early signs show Medicaid expansion under the Affordable Care Act will actually increase the number of Americans who are significantly underinsured – requiring even the poor to spend increasing sums of their own cash to close gaps left by deductibles and co-pays.

In 2003, nearly one in five persons – 18.2 percent – were underinsured according to the definition that they spent more than 10 percent of their family income on health costs, including insurance premiums.

“Paradoxically,” say Drs. Steffie Woolhandler and David Himmelstein of the City University of New York, that number may grow due to the Affordable Care Act. They report in the Journal of General Internal Medicine (published only on April 25, 2013) that CMS seems willing “to allow state Medicaid programs to demand copayments and deductibles, even from the poorest of the poor.”

Underinsurance may also be the fate of middle income persons who join the ACA’s new insurance exchanges. Bronze plans and silver plans under the new system will cover only 60 percent and 70 percent of average medical expenses, respectively. “In effect, the federal government has lent its imprimatur to skimpy plans (long-promoted by private insurers) that offer scant protection from pauperization,” the authors conclude.

Having health coverage through your employer may not mean quite what it used to. Two recent surveys show costs passed on to workers continue to rise at both large and small firms. Strikingly, percentage increases are especially acute for lower wage employees, increasing the overall percentage of family income consumed by health needs.

The 2013 Towers Watson / National Business Group on Health benefits survey showed large employers are moving aggressively to control costs, with only one-quarter of 583 respondents saying they are very confident they will even offer health coverage a decade from now.

The employee share of health care premiums rose 8.7 percent year-over-year from 2012 to 2013, with employees overall paying 42 percent more for care than they did five years previously. “Likewise, out-of-pocket expenses at the point of care continue to rise, up by 15 percent over the last two years, from 15.9% to 18.4%,” the report said, noting that more than 80 percent of companies surveyed plan to continue increasing the premium share paid by workers over the next three years.

Over the last decade, the survey showed drastic increases in the prevalence of account based health plans. Now two-thirds of respondents offer some variation of the approach, which combine health savings accounts with increased deductibles that employees are required to pay. And increasingly, to incentivize participation, companies are offering some form of price, quality, and decision support tools for their employees.

The same trends were noted in a Kaiser Family Foundation/ Health Educational Trust survey last September, which found annual premiums for employer-sponsored family coverage were up 4 percent to $15,745. In the ten years since 2002, the survey found, premiums had nearly doubled, growing three times as fast as wages and more than triple the rate of inflation.

And, cruelly, the bite on lower-wage workers was more aggressive than that on higher-wage workers. “Workers at lower-wage firms on average pay $1,000 more each year out of their paychecks for family coverage than workers at higher-wage firms ($4,988 and $3,968, respectively),” Kaiser Family Foundation said in a press release.

Additionally, “workers at lower-wage firms are also more likely to face high deductibles than those at higher-wage firms. Specifically, 44 percent of covered workers at firms with many low-wage workers face an annual deductible of $1,000 or more, compared with 29 percent of those at firms with many high-wage workers. Across all employers, a third of covered workers (34 percent) face a deductible of that size, including 14 percent with deductibles of at least $2,000 annually,” Kaiser noted.

When Deirdre Yapalater of Long Island was told by her doctor that she needed a colonoscopy, she signed up for one without asking the price or looking for alternatives. But even though her insurer paid the bill, she was stunned by the cost: $6,385 – as compared to less than $1,000 in many other developed countries.

Mrs. Yapalater’s family premiums have gone up 10 percent in the last year, and co-pays are rising – leading her to decline physical therapy for an injury she suffered, and to refuse dermatology medication prescribed for her daughter. Her story is recounted in a major report on the drivers of high medical costs by Elisabeth Rosenthal of The New York Times, published June 1.

Frustratingly, even doctors themselves are often unable to get clear cost information, the Times article showed.

“When Dr. Michael Collins, an internist in East Hartford, Conn., called the hospital that he is affiliated with to price lab tests and a colonoscopy, he could not get an answer,” The Times reports. “It’s impossible for me to think about cost,” he said. “If you go to the supermarket and there are no prices, how can you make intelligent decisions?”

Steven
Brill’s March 4, 2013 cover story in TIME Magazine – “Bitter Pill: Why Medical
Bills Are Killing Us” – weighs in at more than 24,000 words, making it the
longest single-author feature ever published by the prestigious magazine.

In a lively
conversation with Bloomberg TV host Charlie Rose, following publication, Brill
discussed what motivated his research, and what he concludes from it (Interview Part 1and Part 2).

While most of the health care reform debate focused on access to care,
Brill said he thought the question should have been just the reverse – why is
care so incredibly expensive in the first place? As he put it:
“Why will it cost $1 million if you are diagnosed with
cancer? How come? Who’s getting the money?”

Among his findings:

“The bills are indecipherable. They are in
double code. No consumer can understand those bills.”

“Obamacare does nothing to attack the core
problem, which is pricing.”

“Health care is not a marketplace … There’s
nothing free about that market…. There’s no player in the current health care
market, no buyer, who has any leverage over the seller -- except for Medicare,
because it is so big.”

And,
he says, forget the formidable military-industrial complex. The health care
industry eclipses it in power, spending four times as much to lobby Congress.